Air Force Guide for Managing Suicidal Behavior

Strategies, Resources and Tools

APPENDIXES

Point of Contact: Lt Col Rick Campise Air Force Suicide Prevention Program Manager DSN: 297-4285 rick.campise@pentagon.af.mil

Questions about this guide and its use should first be directed to your MAJCOM Behavioral Health Consultant due to variability in implementation across commands

The AF Guide for Managing Suicidal Behavior was developed by: The Air Force Medical Operations Agency (AFMOA) Population Health Support Division (AFMOA/SGZZ) 8320 Laser Road BROOKS AFB TX 78235-5140 Project Manager: Maj Mark S. Oordt

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CONTENTS
APPENDIX A: APPENDIX B: APPENDIX C: APPENDIX D: APPENDIX E: APPENDIX F: APPENDIX G: APPENDIX H: APPENDIX I: Process of Care Flow Chart ................................................. 4 Template for Operating Instruction ...................................... 7 Suicide Assessment Instruments Table............................. 15 Suicide Status Form (SSF-II) ............................................. 18 Suicide Tracking Form (STF-I)........................................... 22 Sample Crisis Response Plan Cards ................................. 27 Sample Risk Assessment Documentation ........................ 29 Suggested SF 600 Suicide Assessment Overprint ........... 31 Sample Memorandum of Understanding with Civilian Inpatient Care Facilities..................................................... 33 APPENDIX J: Template Client Information Sheet ..................................... 36 APPENDIX K: Sample No-Show Letter................................................... 39 APPENDIX L: Access to Care Handout..................................................... 40

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APPENDIX A: Process of Care Flow Chart

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Rec 1

Rec 1 Rec 1

Rec 1

Rec 2

Rec 3

Rec 8

Rec 10

Rec 7

Rec 17

Rec 9 Rec 6

Rec 17

Rec 2

Rec 6

Rec 11

Rec 4

Rec 2

Rec 3 Rec 16

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Rec 5

Rec 11

Rec 12

Rec 4

Rec 18 Rec 13 Rec 13

Rec 15

Rec 13

Rec 11

Rec 11

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APPENDIX B: Template for Operating Instruction

We recommend that each clinic create an Operating Instruction (OI) addressing clinic policy and procedures for managing suicidal behavior. We provided the OI on the following pages as a template for clinics to adapt to the needs of their location. The template addresses the 18 recommendations offered in this guide. References to the recommendations are notated at the end of each item (i.e., Rec #). In various places, this template OI gives direction beyond that offered in the guide (e.g., directing the use of specific screening and assessment instruments and dictating the timeframe for reassessment after hospital discharge). This is simply done to demonstrate that the local OI can dictate specific policies for a given clinic. Local leadership will need to decide on the appropriate specifics for their clinics. Some clinics may adopt this template with minimal changes, while others will modify it substantially or use it as a guide to update an existing OI.

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Medical ASSESSMENT AND MANAGEMENT OF SUICIDALITY IN OUTPATIENT CLINICS This Operating Instruction (OI) establishes a set of guidelines to be followed by outpatient clinics within the Life Skills Support Flight regarding assessment and management of suicidal behavior. 1. References: Air Force Guide for Managing Suicidal Behavior: Strategies, Resources and Tools AFI 44-102, Community Health Management AFI 44-109, Mental Health, Confidentiality and Military Law AFI 44-121, Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Program DoD Instruction 6490, Requirements for Mental Health Evaluations of Members of the

Armed Forces
DoD Directive 6490.1, Mental Health Evaluations for Members of the Armed Forces DoD Directive 6490.4, Requirements for Mental Health Evaluations of Members of the Armed Forces 2. Definitions. 2.1. Suicide Related Behavior: Internal thoughts and external behavior pertaining to taking ones own life. This includes overt actions that are potentially self-injurious, whether or not there is true intent to die. It also includes self-reported suicidal thoughts, verbal or written suicide threats, and preparatory or rehearsal activities related to suicide. (Rec. 3) 2.2. Instrumental Behavior: Suicide-related behavior in which a secondary (interpersonal) gain is driving the individuals actions and there is no intent to die. (Rec. 3) 2.3. Suicidal Acts: Suicide-related behavior in which there is intent to die. (Rec. 3) 3. Responsibilities: 3.1. Mental Health Clinic Staff shall: 3.1.1. Administer the OQ45.2 at the initial visit and flag the suicide screening question (#8) if positive. (Rec. 1) 3.1.2. Notify providers when patients on the high-interest log cancel appointments. (Rec. 11) 3.1.3. Ensure mental health charts of patients on the high-interest log are appropriately marked for easy identification. (Rec. 11) 3.2. Mental Health Technicians shall:

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3.2.1. Provide eyes-on observation for patients awaiting transport to inpatient care. (Rec. 3) 3.2.2. Maintain the high-interest log. (Rec. 11) 3.3. Privileged Providers shall: 3.3.1. Provide appropriate assessment and thorough documentation for individuals who screen positive for elevated risk of suicide. (Rec. 1) 3.3.2. Formulate and document a management plan based on risk level for suicide (Rec. 4) 3.3.3. Place patients who meet criteria on the high-interest log (see 4.31). (Rec. 11) 3.3.4. Monitor patients at elevated risk for suicide at each contact. (Rec. 6) 3.3.5. Follow-up with patients on the high-interest log who do not keep scheduled appointments. (Rec. 11) 4. Procedures: 4.1 Assessment. 4.1.1. Frequency and method. Suicide risk shall be formally assessed at every initial evaluation, and as clinically indicated at follow-up contacts. Multiple methods shall be used to assess suicidality (e.g., screening questions, assessment instruments, interview, collateral information, etc.). Discrepancies in information should be explored and reconciled, and this reconciliation shall be documented. (Rec. 1) 4.1.2. Location. When evaluations are done after clinic hours, they will be conducted in the Emergency Department. They should not be performed in locations where medical support and security is unavailable. (Rec. 16) 4.1.3. Screening. The OQ-45.2 will be administered to all patients with the clinics intake paperwork and the suicide question (#8: I have thoughts of ending my life) will serve as a suicidality screening question. When patients mark 0=Never or 1=Rarely to the OQ-45 question #8, clinical judgment should be used in determining whether suicidal ideation should be readdressed during the clinical interview. Patients marking 2=Sometimes, 3=Frequently or 4=Always shall be further assessed by a privileged provider with regard to current and historical risk factors. (Rec. 1) 4.1.4. Suicide risk assessment. The following areas shall be evaluated and documented as part of the risk assessment (see section 4.5). All of these areas are covered in the Suicide Status Form: (Rec. 1 & 2) 4.1.4.1. Intent: differentiate between desire to commit suicide and actual preparation.

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4.1.4.2. Meanings and motivation for suicide: identify predisposing and precipitating factors; specifically assess perceived burdensomeness to others and feelings of helplessness and hopelessness. 4.1.4.3. Specifics of the plan and rehearsal: Assess when, where, how, and availability; evaluate whether there is adequate knowledge to use the plan; assess how lethal the plan is; evaluate for efforts to prevent rescue; there is notable increased risk when the individual has practiced the plan, so it is important to ask if they have conducted a dry run. 4.1.4.4. Overt suicidal/self-destructive behavior: include prior suicidal behavior, in both the recent and distant past, with focus on whether intent to die was present. 4.1.4.5. Physiological, cognitive and affective states: consider acute and chronic psychopathology. 4.1.4.6. Coping potential and protective factors: consider factors such as social support, evidence of past problem-solving, and investment in current treatment. 4.1.4.7. Impulsivity and self-restraint: use both objective and subjective information. 4.1.4.8. Substance abuse or dependence (past and current). 4.1.4.9. Static risk factors: Age (Risk escalates with age in the general population, although there are no statistical differences between age groups in the active duty population); sex (risk greater for males); previous Axis I or II psychiatric diagnosis; previous history of suicidal behavior; history of family suicide; and history of physical, emotional or sexual abuse. 4.2. Treatment planning and intervention. 4.2.1. Treatment plan. Suicidal behavior as a target for treatment shall be specifically addressed in the written treatment plan. Targeting only underlying conditions (e.g., depression) is insufficient when suicide risk is elevated. (Rec. 4) 4.2.2. Matching intervention to risk level. Suicide risk level shall be determined based on assessment information and matched to an appropriate intervention. Patients who are judged to be a severe or extreme risk for suicide according to the framework in Attachment 1 shall be considered for hospitalization. All patients who are not appropriate for hospitalization, but who are determined to be a mild or higher risk for suicide, will have formal monitoring of suicidal risk at each clinical contact included on their treatment plan. When risk level changes, the treatment plan will be re-evaluated and modified, as appropriate. (Rec. 3) 4.2.3. Limiting access to means. Steps must be taken to safeguard the environment; accessibility to means of self-harm shall be limited. (Rec. 5)

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4.2.4. Limited Privilege Suicide Prevention Program. When active duty individuals being seen in the clinic have been notified that they are under suspicion of a UCMJ offense and are at increased risk for suicide, recommend them for the Limited Privilege Suicide Prevention Program IAW AFI 44-109. (Rec. 7) 4.2.5. Physical Profiling. Recommended duty restrictions should be considered for acutely and chronically suicidal military members and should be documented on an AF Form 422. Providers should evaluate these patients for the appropriateness of an S-4T profile (not worldwide qualified). (Rec. 7) 4.3. Monitoring of Risk. 4.3.1. High-Interest Log. Patients with symptoms and risk factors indicating moderate or higher level of risk (see framework in Attachment 1) shall be entered on the high-interest log. The clinic shall have contact with patients on the high-interest log (either by clinic visit or phone call) no less than once per week and this contact shall be documented. If the patient cannot be reached, attempts shall be documented. The status of each patient on the log will be discussed at the weekly staff meeting. Mental health records of patients on the highinterest log will be tagged with colored tape. Front desk personnel will notify the primary provider when patients on the high-interest log cancel appointments. The primary provider shall contact high-interest log patients who do not show for a scheduled appointment to assess their status. If the patient is active duty and cannot be reached after three tries, the First Sergeant or commander shall be notified. Patients may be removed from the highinterest log after three consecutive assessments in which risk level is deemed mild or below. (Rec. 11) 4.3.2. The Suicide Tracking Form II (STF-II). The STF-II will be used at each clinical contact with all patients who are judged to be at mild risk or higher for suicide. (Rec. 2 & 6) 4.4. Coordinating with inpatient care. 4.4.1. Coordinating with inpatient facilities. Clinic staff will make efforts to maintain contact with inpatient psychiatric staff when active duty members and current patients of the clinic are hospitalized. (Rec. 9) 4.4.2. Reassessment after discharge. Following release from inpatient care or partial hospitalization, a patients needs shall be reassessed by the outpatient clinic before assuming or resuming responsibility for care. This reassessment will occur as soon as possible, but not later than 72 hours after discharge. If the outpatient care is not appropriate for such patients, efforts should be made, and documented, to find care that meets the patients needs. (Rec. 10) 4.5. Documentation.

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4.5.1. Risk assessment. A risk assessment section shall be included in every initial note and all follow-up notes for patients who are at mild or higher risk for suicide. Documentation of a suicide assessment shall include both current and historical risk factors, observations from the session, rationale for actions taken or not taken, and follow-up plans, including a response plan for increased suicidality. (Rec. 8) 4.5.2. Attempts to contact no-shows. Efforts to make contact with patients who no-show for appointments shall be documented. (Rec. 13) 4.5.3. Follow-up with referrals. Patients who are seen for evaluation and then referred out of the clinic shall be contacted within one week by the evaluating provider to determine if they sought out care via the referral. Documentation shall note this follow-up contact and whether or not the patient followed through on the referral (note: it is not the clinics responsibility to ensure that patients follow through on referrals, but only to document the status of the referral). (Rec. 8) 4.6. Clinic support and peer consultation. 4.6.1. Routine consultation. Professional peers shall be consulted regularly regarding highinterest patients. Time at each weekly staff meeting will be allotted for team discussion of high-interest cases. Peer consultation shall be documented in the mental health record. (Rec. 11 & 12) 4.7. Continuity of care issues. 4.7.1. Referred patients. Administrative staff shall contact patients who are referred by other providers and fail to keep their initial appointment to reschedule as soon as possible. The referring provider must also be notified whenever a referred patient fails to keep their initial appointment. (Rec. 13) 4.7.2. Early termination. Patients who notify the clinic that they are dropping out of treatment, before this has been mutually negotiated with the provider, shall be encouraged to continue in care, either through the clinic or through another source of care (e.g., private sector care, primary care, etc.). These discussions shall be documented in the mental health record. When patients do not keep scheduled follow-up appointments or fail to schedule appointments as planned, providers will make (and document) three attempts to contact the patient by telephone in order to assess the situation, and if needed, address barriers to continuing treatment and encourage returning to care. Messages left on telephone answering machines shall generally include the rank and name of the provider (rather than titles like doctor) and not refer to the name of the clinic (e.g., This is Capt Smith from the Medical Group. Please return my call at ext. 5555). If providers are unable to reach the patient after the designated number of attempts, a no-show letter shall be sent. The patients Primary Care Manager shall also be contacted when patients on the high-interest log withdraw from treatment prematurely. (Rec. 13)

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4.7.3. Coverage. The on-call mental health provider will provide coverage to patients who are at increased risk for suicide when the primary provider is not available. Providers shall inform other providers who will have on-call duties of any high-risk cases that may potentially seek care. (Rec. 14) 4.7.4. Transitions. When a provider has a pending PCS move, he or she will conduct a suicide risk re-assessment for all active patients who have been determined to be at increased risk for suicide during their course of care. Patients who are at increased risk for suicide must be monitored for risk using the STF-II on at least a weekly basis if there is a wait for a follow-on provider and will be prioritized for reassignment to another provider. (Rec. 15) 4.8. Support to commanders and First Sergeants. 4.8.1. Consultative role. Mental health flight personnel are the primary mental health resources on an installation and must be available for both consultative and patient care roles. When unit leadership has expressed concern about an active duty individuals suicide risk, it is generally inappropriate to return such individuals to duty without ongoing contact or follow-up with the leadership and/or the patient. The provider shall inquire as to what support is needed or desired by the commander and First Sergeant regarding management of this individual. (Rec. 17) 4.8.2. Ethical Issues. Appropriate levels of confidentiality shall be maintained within the limits of Air Force instructions (e.g., AFI 44-109, Mental Health, Confidentiality and Military Law), law, and commanders legitimate need to know. Providers must be cautious with regard to issues of dual relationship, as well. When meeting with the patient, the provider shall clearly spell out the nature of his or her role as consultant to the commander. (Rec. 17)

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Attachment 1 Framework for Determining Risk for Suicide

Risk Level Criteria for Multiple Attempters

Risk Level No significant risk Mild Moderate Severe Extreme Multiple attempters fit this risk level if the following findings are present: Never No other symptoms or indicators from SDI or RPP factors (see table on page 20) or other risk factors1 Any symptom or indicator from either the SDI or RPP factors or other positive risk factor1 Two or more positive findings1 including SDI or RPP symptoms or indicators Severe symptoms or indicators of the RPP factor

Risk Level Criteria for Non-Multiple Attempters

Risk Level No significant risk Mild Non-multiple attempters fit this risk level if the following findings are present: No identified SDI or RPP suicidal symptoms or indicators (see table on page 20) and few other risk factors1 Suicidal ideation of limited intensity or duration, but no or mild symptoms or indicators from the RPP factor and few other risk factors1 Moderate to severe symptoms or indicators from the RPP factor, OR no or few symptoms or indicators from the RPP factor, but moderate to severe symptoms or indicators from the SDI factors, and at least two other positive risk factors1 Moderate to severe symptoms or indicators from the RPP factor and at least one other risk factor1 Severe symptoms or indicators from the RPP factor and two or more other risk factors1

Moderate

Severe Extreme

Other risk factors include acute and chronic psychopathology, history of impulsivity and poor self-restraint, substance abuse or dependence, and significant psychosocial stressors. Do not include static risk factors (see page 16) in these criteria.

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APPENDIX C: Suicide Assessment Instruments Table

The following table, adapted from Greg K. Browns (2001) manuscript entitled A Review of Suicide Assessment Measures for Intervention Research with Adults and Older Adults, contains a comprehensive listing of suicide assessment measures for adults. Discussion of each instrument and contact information for obtaining them can be found in the source article available on the National Institute of Mental Health (NIMH) website: www.nimh.nih.giv/research/adultsuicide.pdf

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Suicide Assessment Measures (adapted from Brown, 2001)

Measure Mode of Administration Self-Report Scale for Suicide Ideation Beck Scale for Suicide Ideation Modified Scale for Suicide Ideation Self-Monitoring Suicide Ideation Scale Suicide Intent Scale Parasuicide History Inventory Suicide Behavior Questionnaire Suicide Behavior Questionnaire-Revised Suicide Behavior Interview Suicide Probability Scale Positive and Negative Suicide Ideation Inv. Adult Suicide Ideation Questionnaire Suicide Ideation Scale Suicide Status Form Firestone Assessment of Self-Destructive Thoughts Risk-Rescue Self-Inflicted Injury Severity Form Lethality Scales Paykel Suicide Items Symptom Driven Diagnostic System for Primary Care (Suicide Items) Suicide Ideation Screening Questionnaire Hamilton Rating Scale for Depression (Suicide Item) Beck Hopelessness Scale Beck Depression Inventory (Suicide Item)
2

Factors

Items

Interview X 2 3 X 2-3 21 21 18 3 X X 2 4 15 48+ 4 1 X 34 4 6 2 4 36 20 25 10 6 3 X X X X 6 84 10 7 8 5 3

Predictive Validity X

Study Settings2

P, M, COL, C P P, COL COL

P, M P P, COL P, COM O P, M, COL, C COL P, COL, C COL COL3 P, COL P, M M P, M C M

X X

X X X X X X

X X

4 1 X

M, C P

X X

20 1

X X

P, M, COL P, M, COL

P=Psychiatric, M=Medical, COL=College, C=Community, O=Other Data from U.S. Air Force samples also exist (Jobes, Wong, Drozd & Kiernan, 2002)

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Suicide Assessment Instruments (adapted from Brown, 2001), Continued

Mode of Administration Measure Linehan Reasons for Living Inventory Brief Reasons for Living Inventory College Student Reasons for Living Inv. Suicide Opinion Questionnaire Suicide Potential Lethality Scale Quiz on Depression & Suicide in Late Life Suicide Intervention Response Inventory Self-Report X X X X X X X 12 4 25 Interview Factors 6 6 6 5-15 Items 48+ 12 46 100 13 Predictive Validity Study Settings4 P, M, COL, C O P, C COL, C, O C, O COL, C, O C, O

P=Psychiatric, M=Medical, COL=College, C=Community, O=Other

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APPENDIX D: Suicide Status Form (SSF-II)

Suicide Status Form, Suicide Tracking Form, and Suicide Tracking Outcome Form Copyright David Jobes, 2000. Permission to reproduce and use in Air Force clinics granted by the author.

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APPENDIX E: Suicide Tracking Form (STF-I)

Suicide Status Form, Suicide Tracking Form, and Suicide Tracking Outcome Form Copyright David Jobes, 2000. Permission to reproduce and use in Air Force clinics granted by the author.

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APPENDIX F: Sample Crisis Response Plan Cards

These Crisis Response Plan Cards, adapted from Rudd, Joiner and Rajab (2001), are samples of what can be provided to patients to carry in their wallet or purse for use when they experience suicidal thoughts and feelings. They can be generic or personalized for each patient. For easy formatting and printing, use Avery Standard Form 5371 (Business Card) in your Microsoft Word program (click on Tools, Envelopes and Labels, Options).

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Crisis Response Plan When thinking about suicide, I agree to do the following: Step 1: Try to identify my thoughts and specifically what's upsetting me Step 2: Write out and review more reasonable responses to my suicidal thoughts Step 3: Do things that help me feel better for about 30 min (e.g., taking a bath, listening to music, going for a walk) Step 4: Repeat all of the above Step 5: If the thoughts continue, get specific, and I find myself preparing to do something, I call the LSSC at: ______________ Step 6: If I cannot reach anyone at LSSC, I call: ______________ Step 7: If I'm still feeling suicidal and don't feel like I can control my behavior, I go to the emergency room

Crisis Response Plan When thinking about suicide, I agree to do the following: Step 1: Try to identify my thoughts and specifically what's upsetting me Step 2: Write out and review more reasonable responses to my suicidal thoughts Step 3: Do things that help me feel better for about 30 min (e.g., taking a bath, listening to music, going for a walk) Step 4: Repeat all of the above Step 5: If the thoughts continue, get specific, and I find myself preparing to do something, I call the LSSC at: ______________ Step 6: If I cannot reach anyone at LSSC, I call: ______________ Step 7: If I'm still feeling suicidal and don't feel like I can control my behavior, I go to the emergency room

Crisis Response Plan When thinking about suicide, I agree to do the following: Step 1: Try to identify my thoughts and specifically what's upsetting me Step 2: Write out and review more reasonable responses to my suicidal thoughts Step 3: Do things that help me feel better for about 30 min (e.g., taking a bath, listening to music, going for a walk) Step 4: Repeat all of the above Step 5: If the thoughts continue, get specific, and I find myself preparing to do something, I call the LSSC at: ______________ Step 6: If I cannot reach anyone at LSSC, I call: ______________ Step 7: If I'm still feeling suicidal and don't feel like I can control my behavior, I go to the emergency room

Crisis Response Plan When thinking about suicide, I agree to do the following: Step 1: Try to identify my thoughts and specifically what's upsetting me Step 2: Write out and review more reasonable responses to my suicidal thoughts Step 3: Do things that help me feel better for about 30 min (e.g., taking a bath, listening to music, going for a walk) Step 4: Repeat all of the above Step 5: If the thoughts continue, get specific, and I find myself preparing to do something, I call the LSSC at: ______________ Step 6: If I cannot reach anyone at LSSC, I call: ______________ Step 7: If I'm still feeling suicidal and don't feel like I can control my behavior, I go to the emergency room

Crisis Response Plan When thinking about suicide, I agree to do the following: Step 1: Try to identify my thoughts and specifically what's upsetting me Step 2: Write out and review more reasonable responses to my suicidal thoughts Step 3: Do things that help me feel better for about 30 min (e.g., taking a bath, listening to music, going for a walk) Step 4: Repeat all of the above Step 5: If the thoughts continue, get specific, and I find myself preparing to do something, I call the LSSC at: ______________ Step 6: If I cannot reach anyone at LSSC, I call: ______________ Step 7: If I'm still feeling suicidal and don't feel like I can control my behavior, I go to the emergency room

Crisis Response Plan When thinking about suicide, I agree to do the following: Step 1: Try to identify my thoughts and specifically what's upsetting me Step 2: Write out and review more reasonable responses to my suicidal thoughts Step 3: Do things that help me feel better for about 30 min (e.g., taking a bath, listening to music, going for a walk) Step 4: Repeat all of the above Step 5: If the thoughts continue, get specific, and I find myself preparing to do something, I call the LSSC at: ______________ Step 6: If I cannot reach anyone at LSSC, I call: ______________ Step 7: If I'm still feeling suicidal and don't feel like I can control my behavior, I go to the emergency room

Crisis Response Plan When thinking about suicide, I agree to do the following: Step 1: Try to identify my thoughts and specifically what's upsetting me Step 2: Write out and review more reasonable responses to my suicidal thoughts Step 3: Do things that help me feel better for about 30 min (e.g., taking a bath, listening to music, going for a walk) Step 4: Repeat all of the above Step 5: If the thoughts continue, get specific, and I find myself preparing to do something, I call the LSSC at: ______________ Step 6: If I cannot reach anyone at LSSC, I call: ______________ Step 7: If I'm still feeling suicidal and don't feel like I can control my behavior, I go to the emergency room

Crisis Response Plan When thinking about suicide, I agree to do the following: Step 1: Try to identify my thoughts and specifically what's upsetting me Step 2: Write out and review more reasonable responses to my suicidal thoughts Step 3: Do things that help me feel better for about 30 min (e.g., taking a bath, listening to music, going for a walk) Step 4: Repeat all of the above Step 5: If the thoughts continue, get specific, and I find myself preparing to do something, I call the LSSC at: ______________ Step 6: If I cannot reach anyone at LSSC, I call: ______________ Step 7: If I'm still feeling suicidal and don't feel like I can control my behavior, I go to the emergency room

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APPENDIX G: Sample Risk Assessment Documentation

These notes provide a sample of the content that comprise a comprehensive suicide risk assessment. While abbreviations and succinct writing can shorten them, they are presented to demonstrate the type of documentation that is recommended. The Suicide Status Form (SSF) and SF600 overprint in this guide can provide alternative means for documenting this clinical content.

A. From an Intake Note

Suicide/Homicide Risk Assessment: Precipitant: The patient's recent suicide attempt (overdose with aspirin) was precipitated by the breakup of his five-year marriage and separation from his two children (ages 5 and 7). Details of the attempt are noted below. The couple is currently separated and the patient has limited weekly-supervised contact with his children. Static Factors: His past history is positive for one suicide attempt without injury, an overdose attempt (aspirin) at the age of 16. The patient expressed subjective intent to die at the time, but there were no objective markers of intent. The number of aspirin taken was small and the lethality very limited (reported at "about ten"). The patient noted that he took them "in front of his parents" who immediately took him to the emergency room. No medical care was required and he was released to his parents supervision after a brief evaluation. Although follow-up psychological care was recommended, he did not follow through. There was no evidence of any preparatory, planning, or rehearsal behavior of any type. Additionally, he added that he was "glad that he didn't really hurt himself". The patient reported that the first suicide attempt was "impulsive" and motivated by "anger" at his parents for "grounding him". He denied any alcohol or substance abuse of any type at the time, with no evidence of cognitive impairment. There is no reported history of abuse of any type (physical, sexual, emotional) and no reported history of diagnosed psychiatric illness or treatment. Aggravating Factors: As noted above, the patient overdosed on a "handful of aspirin". The attempt required no medical care although he was taken to the emergency room. He was evaluated and released to home, with scheduled outpatient follow-up. The patient reported subjective intent to die but there were no objective markers of intent. The patient took the overdose "in front of his wife", reports that he was again "being impulsive", with no associated preparatory, planning, or rehearsal behaviors of any type. At present, the patient reported no suicidal thoughts whatsoever, intent, or plans of any type. He also reported no access to a method, with all medications having been removed from the home. This was confirmed with a family member (see signed release form). Prior to the attempt, the patient denied any significant suicidal ideation, noting episodic thoughts the week prior that would endure for "a few seconds". Accordingly, he rated the severity of his suicidal ideation as a 1 on a 1 (none) to 10 (severe) scale. When asked about reasons for living/dying, the patient stated that he "lives for his kids" and "wouldn't kill himself because it would hurt them too much". He denied any prominent symptoms of any type and also denied any substance abuse of any type (current or previous). There was no additional evidence of substance abuse or associated cognitive impairment. He rated depressive and anxiety symptoms both as a 1 on a 1 (none) to 10 (severe) scale. He reported that he was hopeful about the future, despite his pending divorce, scoring a 2 on a 1 (hopeful) to 10 (hopeless) scale of hopelessness. Previously identified cognitive themes for 29

hopelessness include: unlovability and poor distress tolerance. Although the patient denies being impulsive, there is clear objective evidence of impulsivity related to the two previous suicide attempts. There is no evidence of associated instrumental behavior. Chronic Risk: There is no current evidence to suggest that the patient is at chronic risk. Acute Risk: Current risk is estimated as minimal. Suicidality Management Plan: 1. The patient will initiate individual psychotherapy and concurrent marital therapy to address separation. 2. Current symptom severity is not adequate to warrant referral for medication evaluation, nor does the patient want such a referral. 3. The patient has signed a commitment to treatment statement, see attached. 4. The patient has demonstrated the ability to, and has agreed to make use of, his crisis response plan, see attached.

B. From a Follow-up Note

Suicide/Homicide Risk Assessment: Precipitant: The patient continues to experience significant marital distress but is actively engaged in marital therapy. Static Factors: Noted in previous entry (at intake). Aggravating Factors: The patient reports no active suicidal thoughts (rating of 1) and no related intent, plans, or behaviors. There have been no additional attempts since last session, with no current access to medications. Symptom reports are unchanged from last session. He reported that he was hopeful about the future, scoring a 1 on a 1 (hopeful) to 10 (hopeless) scale of hopelessness. Previously identified cognitive themes for hopelessness include: unlovability and poor distress tolerance and are actively being addressed. No evidence of impulsive or instrumental behavior since last session. Chronic Risk: There is no current evidence to suggest that the patient is at chronic risk. Acute Risk: Current risk is estimated as minimal. Suicidality Management Plan: 1. The patient will continue in individual psychotherapy and concurrent marital therapy to address separation. 2. No current symptoms and no indicated need for a medication referral. 3. The patient has signed a commitment to treatment statement and is in compliance. 4. The patient has demonstrated the ability to, and has agreed to make use of, his crisis response plan, see attached.

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APPENDIX H: Suggested SF 600 Suicide Assessment Overprint

S. A comprehensive suicidality assessment was conducted due to: (check one) ___ Referral source identified suicidal symptoms or risk factors ___ Patient reported suicidal thoughts/feelings on intake paperwork/assessment tools ___ Patient reported suicidal thoughts/feelings during the intake interview ___ Recent event already occurred ___ Other: Y N Suicide Ideation: Frequency: Intensity: Duration:

Never Rarely Sometimes Frequently Always Brief and fleeting Focused deliberation Intense rumination Other: _____________________________________ ____ Seconds ____ Minutes ____Hours

Y N Current Intent Subjective reports: __________________________________________________ Objective signs: ____________________________________________________ Y N Suicide plan: When___________________________________________________________ Where___________________________________________________________ How_______________________________________ Y N Access to means Y N Suicide Preparation ___________ _____ Y N Suicide Rehearsal_____________________________________________________________ Y N History of Suicidality Ideation____________________________________________________________________ Single Attempt______________________________________________________________ Multiple Attempts____________________________________________________________ Y N Impulsivity Subjective reports: _______ Objective signs: _____________________________________________________________ Y N Substance abuse Describe: Y N Significant loss Describe: Y N Interpersonal isolation Describe: Y N Relationship problems Describe: Y N Health problems Describe: Y N Legal problems Describe: Y N Other problems Describe: Y N Homicidal ideation Describe: Additional risk factors: (check all that apply) ____ Age over 60 ____Male ____Previous Axis I or II psychiatric diagnosis ____ Previous history of suicidal behavior ____History of family suicide ____ History of physical, emotional or sexual abuse ___ Access to firearms

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O: Alertness: alert drowsy lethargic stuporous other: Oriented to: person place time reason for evaluation Mood: euthymic, elevated, dysphoric, agitated, angry, Affect: flat, blunted, constricted, appropriate, labile Thought continuity: clear and coherent, goal-directed, tangential, circumstantial, other: Thought content: WNL, obsessions, delusions, ideas of reference, bizarreness, morbidity, other: Abstraction: WNL, notably concrete, other: Speech: WNL, rapid, slow, slurred, impoverished, incoherent, other: Memory: grossly intact, other: Reality testing: WNL, other: Notable behavioral observations: A: Current level of suicide risk: No Significant Risk DSM-IV-R Diagnosis: Axis I: Mild Moderate Severe Extreme

Axis II:

Axis III: Axis IV: Axis V: P: At the current time, outpatient care can/cannot provide sufficient safety and stability. Intervention plan for safety is: 1. 2. 3. 4. Patient agrees to this plan: Y N Patient was provided a written crisis response plan: Y N Patient will be entered on the high-interest log: Y N Hospitalization is / is not necessary. Rationale: Special precautions necessary: Persons notified of increased risk: spouse / commander / First Sergeant / PCM / friend / none / other: Additional Information:

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APPENDIX I: Sample Memorandum of Understanding with Civilian Inpatient Care Facilities

This sample Memorandum of Understanding can be adapted for use with civilian inpatient facilities to help facilitate collaborative care. The sample focuses on referral and admission procedures, communication between the Life Skills Support Center and the civilian facility, and collaboration in discharge planning. Local MTFs may choose to augment this memorandum to address agreements on financial arrangements, transportation responsibilities, pre-authorization issues, etc.

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MEMORANDUM OF UNDERSTANDING

I. Background 1. This agreement is entered into by and between the XX medical group, XXXX Air Force Base and XXXX hospital, hereinafter facility. II. Understanding: The parties acknowledge and agree to the following: 2. When a patient needs transfer from one of the above named medical groups to the other above named facilities, the receiving facility agrees to admit the patient as promptly as possible, without regard to race, color, creed, age, sex, handicap or national origin in accordance with Federal and State Laws and regulations, provided admission requirements are met and bed space to accommodate the patient is available. 3. Admissions to aforementioned facility. 3.1 The Life Skills Support Center (LSSC) may refer patients directly to the aforementioned facilities without waiting for the assessment team to travel to the hospital and assess the individual in question. 3.2 LSSC will send a copy of the assessment performed on the patient in addition to the consult report to TRICARE. 3.3 For active duty military members and non-active duty patients who have active LSSC cases, LSSC staff will attempt to obtain signed consent for release of information from the patient using the facilitys consent forms prior to transfer to the facility. If this is not possible, the facility will request consent for release of relevant medical information to the LSSC. LSSC staff will also request consent to release relevant information from LSSC evaluations and treatment to the facility to enhance continuity and collaboration in providing care. 3.4 Following admission, and in the event that consent for release of information is granted, the facility will provide LSSC with information related to diagnosis, clinical status, and nature of treatment being provided, upon request. 4. Discharge from the aforementioned facility: 4.1 At least 24 hours prior to discharge of military personnel the facility will contact the LSSC or the on-call mental health provider (phone number XXX-XXXX) to notify the clinic of the pending discharge. The facility will arrange a follow-up appointment with the LSSC, to occur within XX hours of discharge. 4.2 Military personnel will stay the number of days determined by the facilitys provider to be clinically necessary or as contracted by the facility with the following exception: 34

If the discharge date falls on a Saturday or Sunday, the patient is to be discharged on that Friday before the weekend or the Monday immediately following.

4.3 A copy of the treatment summary and discharge plan will be provided to patients upon discharge. For military members, it will be faxed to the LSSC at XXX-XXXX.

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APPENDIX J: Template Client Information Sheet

The Client Information Sheet on the following page is an adaptation of AFI 44-109, Attachment 2. We have changed it to reflect information that clients should know prior to engaging in evaluation and treatment, consistent with the recommendations in this guide. In accord with the AFI, local MTFs may modify the consent form when local conditions dictate; however, they must address each of the elements in Attachment 2. This Client Information Sheet may also be useful as a handout for educating commanders and First Sergeants about issues of privacy and confidentiality, and the type of communication they can expect from mental health personnel.

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MENTAL HEALTH CLINIC CLIENT INFORMATION SHEET

Clients are often unsure what to expect in a mental health clinic. We encourage you to consider the following points regarding mental health care, and to discuss them with your provider if you wish. You can expect the attention, respect, and best professional efforts of your provider. Your provider will treat you as a responsible individual and will expect you to take an active part in your treatment. You should also expect to take part in the treatment decisions. You should understand the goals and direction therapy is taking, and if you do not understand, you should ask. Before initiating a professional evaluation or treatment relationship with a provider, we want you to know about privacy ground rules. Generally, information discussed during the evaluation and treatment sessions is confidential and may not ordinarily be revealed to anyone outside the clinic without your permission. It is sometimes helpful to involve others (such as unit leadership, family, etc.) in your evaluation or treatment. Your provider will obtain your consent before contacting them or releasing information. Under some limited circumstances, however, information may be released without your permission. These are discussed below: Records of Your Care. Every client visit to mental health is documented in the outpatient medical record. These entries are as brief as possible to protect your privacy. It is important, however, that providers caring for you in other clinics be aware of the care you are receiving here. Detailed notes documenting your mental health care are maintained in your mental health record. The mental health record is secured in the mental health clinic. Disclosure Policy and Non-Active Duty Clients. The privacy of non-active duty clients is protected by the Federal Privacy Act and is not generally governed by other military regulations, unless the individual is also a Department of Defense employee. Most information related to the treatment of non-active duty clients is not releasable without the written consent of the client. Excluded from consent requirements are such activities as quality assurance reviews by other mental health professionals and collection of information for medical research (without personal identifiers). Other releases generally require your written consent. Exceptions for active duty and non-active duty include: Access to Information by Commanders. Commanders may obtain access to the records of their members to ensure fitness for duty or a clients record when the contents of mental health records are essential to the accomplishment of a military mission. Additionally, commanders will be notified if a members condition impacts suitability for certain duties. Child or Spouse Maltreatment. Providers must report suspected child abuse or neglect, and other incidents of family maltreatment to military agencies, local child protective authorities, or both. Crimes or Fraud. Providers must report any threat to commit crimes or fraud by non-military as well as military clients.

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Danger to Self or Others. Providers must take steps to protect individuals from harm when the client presents a serious threat to the life or safety of self or others. This involves consultation with your Primary Care Manager and other medical/behavioral health staff and involvement of your commander and/or First Sergeant (for active duty members). In cases of very high risk, hospitalization may be necessary. It is our policy to contact clients who have increased risk factors for suicide if they do not keep a scheduled appointment. If we are unable to reach the client, we will notify someone who can help check on their status (including the commander or First Sergeant, if active duty). Exception for active duty only include: Drug or Alcohol Abuse. Providers must report all suspected instances of drug/alcohol abuse by active duty clients to rehabilitation programs and commanders. By signing this form, you acknowledge that you have been informed of the information it contains and understand it.

Signature ______________________________ Date _____________

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APPENDIX K: Sample No-Show Letter

Date MEMORANDUM FOR PATIENTS NAME FROM: XX Medical Group/SGOH XXX AFB SUBJECT: Missed appointment

You missed a scheduled appointment at the Life Skills Support Center (LSSC) on [date] at [time]. I attempted to contact you by phone to see how you are doing, however, I have been unable to reach you. If you would like to reschedule this appointment, please contact the clinic at (XXX) XXX-XXXX. If there have been any barriers or problems with regard to continuing your care at LSSC, we hope you will call and discuss these with us. If we do not hear from you in the next couple weeks, we will assume that you are no longer interested in services at this time and will close your file. LSSC services will continue to be available to you in the future. Alternate sources of care include the primary care clinic or a TRICARE network provider (for non-active duty beneficiaries).

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APPENDIX L: Access to Care Handout

We have provided the handout on the following page as a way of communicating with patients about accessing care, both routine and urgent. You may adapt it fit the needs of your facility.

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The Life Skills Support Center (LSSC) is dedicated to promoting wellness and helping individuals during difficult life situations. Routine follow-up appointments can be made after your appointment or by calling the appointment line at XXX-XXXX. If you need to talk briefly with your provider between appointments, call the LSSC at XXX-XXXX. If your provider is unavailable, you may leave a message and someone will call you as soon as possible. If your situation is an emergency and need to speak with a provider urgently, you should follow our emergency procedures. Thoughts or feelings about suicide that you may not be able to control, or other fears about your immediate personal safety should be considered an emergency.

Emergency Procedures
Between 0730 and 1630: Call the LSSC at XXXXXXX and inform the receptionist that this is a crisis situation. Your name and phone number be taken and you will be contacted by the on-call mental health provider. After clinic duty hours: Go to the emergency department (If your base does not have an emergency room, provide the name, number, and location of civilian emergency department). You may also call 9-1-1.

* Modify highlighted areas to reflect your MTF

Life Skills Support Center

Procedures for Accessing Care

XXth Medical Group XXXXX AFB Phone: (XXX) XXX-XXXX Clinic Hours: 0730 1630, M-F